L’Shana Tova from FJMC, MRJ and HWR.

We are welcoming new groups of readers from FJMC and MRJ.  We hope you enjoy these articles about your Health and Wealth.  Be sure to scroll through the issue. We welcome articles from our readers on most any topic including biographical, professional or testimonial themes.  Browse the archives at fjmc.org– Publications – Health, Wealth and Retirement Newsletters.
 
This issue has 4 articles to give a taste of our range.

1. Health Tip – BRCA Mutation Significance, Prevalence, and Treatment Options, by Wojciech Dec, MD through Medical Editor Steven Mandel, MD
2. Wealth Tip – Don’t miss this Bull Market by Gary Smith
3. Member Profile – Norm Kurtz
4. Security Tip - Cyber Security, Could You or Your Business be Infected  by Richard Freiberg 

Please do not miss the overt and underlying messages of all these articles that FJMC continues to be a place that we need to be participating in with our financial support as well as our time.

Be sure to be in touch with Richard Gray, Editor, at rgray@fjmc.org with your articles, comments, appreciation and critiques. Each issue is brought to you by your editorial staff that includes:

• Richard Gray (Editor in Chief)
• Steven Mandel MD (Medical Editor)
• Gary Smith (Wealth Editor)
• Mark Druy (Publisher)

This HWR was sent out on , at approximately 9:30 PM (Eastern and prior to Shabbat).

The majority of patients with hereditary breast and ovarian cancer have mutations in either the BRCA1 or BRCA2 genes. These mutations disrupt the body’s ability to repair DNA, which results in an increased susceptibility to cancer. In these families there are frequently several generations of women affected by breast and ovarian cancer, often at a young age. Other malignancies such as prostate, male breast, melanoma, and pancreatic cancers may also be observed
 
Prevalence

The prevalence of BRCA mutations varies based on a number of factors. In the United States the chance of a harmful BRCA mutation is 1 in 400 people, however the frequency increases to 1 in 40 in Ashkenazi Jewish patients. Increased frequency in BRCA mutations have been reported worldwide in individuals from: the Netherlands, Sweden, Hungary, Iceland, Italy, France, South Africa, Pakistan, Asia, French Canadians, Hispanics, and African Americans.
 
Risk

The lifetime risk of developing breast and ovarian cancer has been reported as 72% and 44% respectively for patients carrying the BRCA 1 mutation and 69% and 17% for patients carrying the BRCA 2 mutation. With a mean age of diagnosis for breast cancer of 43 years for BRCA 1 patients and 47 years for BRCA 2 patients. Risk of other cancers associated with BRCA mutations are also increased but are not as high as those observed with breast and ovarian cancer.
 
Genetics researchers are continually finding mutations in genes that are linked to developing certain cancers. The following personal and/or family characteristics suggest an individual should be tested for such a mutation:

• Breast cancer before the age of 50
• Triple-negative tumor (ER-PR-HER2 negative) in someone younger than 60
• Ashkenazi Jewish heritage and breast cancer at any age
• Two or more breast cancers in one individual
• First-degree relative with breast cancer diagnosed before age 50
• Two relatives on the same side of the family with breast cancer and/or pancreatic cancer
• Family or personal history of ovarian cancer, fallopian cancer, or primary peritoneal cancer
• Male breast cancer
• Known mutation carrier in the family

Surveillance

For patients who wish to delay surgical risk reduction, breast cancer surveillance and ovarian cancer screening may be offered. Patients should be educated regarding the signs and symptoms of breast, ovarian, and other associated cancers.
 
Breast Evaluation

Beginning at the age of 18 self breast exams may facilitate awareness of changes. Clinical breast exams should be performed every 6 to 12 months beginning at age 25.
 
Annual Mammography

Mammography should begin at age 30 or 5 years before the earliest age of cancer diagnosis in the family. While the risk of radiation associated breast cancer from mammography is believed to be small it needs to be weighed against the diagnostic benefits of mammograms starting at an earlier age.
 
Magnetic Resonance Imaging (MRI) and Other Modalities

MRI for breast cancer screening is recommended annually beginning at age 25 and should be staggered by 6 months with annual mammograms. Data regarding the role of screening breast ultrasound have not demonstrated additional benefit in BRCA patients.
 
Ovarian Cancer Screening

BRCA mutation carriers who have not undergone removal of the ovaries may undergo ultrasound and CA-125 blood screening every 6 months beginning at age 30 or 5 to 10 years before the earliest age of a relative diagnosed with ovarian cancer.
 
Men with a BRCA Mutation

There are no proven risk reducing surgical options for male BRCA mutation carriers. Therefore the following screening strategy is recommended:

• Monthly breast self exams starting at age 35
• Clinical breast evaluation every 12 months starting at age 35
• Men should discuss with their clinician the role of baseline mammogram at age 40
• Prostate cancer screening starting at age 40 

Other Cancer Screening

There is no consensus regarding screening for melanoma or pancreatic cancer. Possible recommendations involve full body skin exams and research trials for pancreatic cancer screening. Guidelines for colon cancer screening in BRCA mutation carriers do not differ from those in the general population. However, if an individual has a family history of colon cancer or a prior adenoma, then more aggressive screening may be recommended.
 
Chemoprevention

Chemoprevention strategies to reduce the risk of cancer have focused on estrogen receptor modulators and aromatase inhibitors in women at high risk women for breast cancer. The use of oral contraception in women with a BRCA mutation may reduce the risk of ovarian cancer but may increase the risk of breast cancer.
 
Other Mutations

For women who carry mutations in genes other than BRCA that confer moderate risk for breast cancer like PALB2, CHEK2, and ATM the options for breast cancer prevention are similar to BRCA mutation carriers.
 
Mastectomy

Risk reducing removal of both breasts decreases cancer by as much as 90%. However, risk reducing surgery does not completely eliminate the risk of developing cancer. Patient with a BRCA mutation are increasingly being offered skin sparing mastectomy with or without preservation of the nipple and areola because of superior cosmetic results.
 
Breast Reconstruction

Most patients undergoing prophylactic mastectomy are candidates for immediate breast reconstruction. A greater focus on good cosmetic results is possible in this group of patients who are unlikely to require postoperative chemotherapy or radiation treatment. Surgical techniques such as nipple sparing mastectomy and hidden scar mastectomy can often be utilized.
 
Bilateral Salpingo-Oopherectomy

Patients who carry a BRCA mutation should be referred to a gynecologic oncologist for a discussion about preventative surgeries. Removal of the fallopian tubes and ovaries is the most effective approach to reduce risk and decreases the risk of ovarian cancer in BRCA patients by 80%. Pre and peri-menopausal women who undergo removal of the ovaries will likely experience side effects of surgically induced menopause. Currently there is limited data on the use of hormone replacement therapy in these patients and how hormone therapy may affect breast cancer risk.
 
Fertility Preservation

Women considering removal of the ovaries who have not completed childbearing should be counseled about alternative reconstructive options. For women who wish to preserve their ability to have a genetic child embryo or oocyte cryopreservation is an option.
 
Treatment of BRCA carriers with a Personal History of Cancer

Treatment of patients who undergo genetic testing after they have been diagnosed with cancer is more complex. Women who are candidates for breast conservation therapy may opt to undergo double mastectomy to reduce their risk of a second breast cancer. Risk reducing bilateral slapping oophorectomy should be recommended in mutation carriers with a breast cancer diagnosis.
 
Treatment of prostate cancer in men with a BRCA mutation does not differ from sporadic prostate cancer treatment. However, because prostate cancer in BRCA carriers is more aggressive, treatment with surgery or radiation may be recommended instead of active surveillance.
 
The BRCA Center

Care for patients with a BRCA mutation requires a multidisciplinary team consisting of: breast specialists, breast radiologists, gynecologic oncologists, fertility specialists, plastic surgeons, and genetic counselors. Because of the broad expertise required to deliver comprehensive care patients will ideally be treated in a BRCA Center.

About the Author

Dr. Wojciech Dec is a board certified plastic surgeon specializing in breast reconstruction at the NY BRCA Center in Lenox Hill Hospital in New York, NY.  For more information please contact the BRCA Center at info@BRCAcenter.com.

Wow! What a thought. If you missed out so far on nine years of gains can you still invest and make money in the bull market?  When will it end?  I am an individual investor. How do I compete with the big companies?  All these are great questions. 
 
We are in the midst of a Melt Up in the Bull Market. The market has gone up for the last 15 out of 16 years and 9 years straight.  Pretty amazing!  I am here to tell you that I think the market will continue higher. We are in a melt up and yes the bubble will eventually burst.  Bubbles burst when something drastic has changed.  For now Interest rates are low,  companies are making record profits, unemployment is low and many other positive factors are in play.  Despite stocks being at their all-time highs they are still not expensive.  Let’s take a look at stock PE ratio based on 12 months forward earnings which is the most common measure of value.

The S&P forward PE trades for 17.5 which is lower than a year ago. The stock market is not expensive today. This means there is room for it to run. There is a lot of room to run but we must remember we are in the bottom of the 9th inning of this bull market. We may have 6 months or 12 months. There is no way of knowing. Further there is still a lot of cash on the sidelines. People are waiting and afraid. Once all that money and individual investors start flocking in then the big boys know to get out. When PE ratios hits 20 or above caution must be exercised.

What will change the picture?

Interest rates, inflation, increased unemployment, earnings drops, etc are change engines.  Again it is not too late to get into this bull market.  But, you must have a sound strategy on getting in and when to get out. You can make 2-3 times your money in this 9th inning melt up. To prevent big losses the strategy should include stop losses, position sizing, asset allocation and having cash all the time.  More technically, watch the volume (up days have less volume and down days have higher volume) and pay attention to stocks PE ratio.  Don’t invest more than you can afford to lose, be in touch with your financial planner, and don’t make your spouse too nervous.
 
You can make more gains then you have ever imagined.  There are still some areas of the market that have not been included in the bull run, i.e. marijuana stocks.  There are also always trends that in every bull market will explode i.e. technology and biomedical.
 
Editors note:
Check out more Wealth articles in the archives at fjmc.org– Publications – Health, Wealth and Retirement Newsletters. This year’s other articles can help you with tools for smarter investing.

Good Investing!

I hope you enjoyed this wealth tip. It is fun to write and your feed back is important.  It will hopefully to trigger your own research and you will make rational sound decisions.  Let me know if you have any questions by contacting me at gsmith@fjmc.org.  This article is from personal research and various articles written by Porter Stansberry and Warren Buffet, and investing books such as “The Death of Money”.

For the past thirty-five (35) years Men’s Club has been an essential part of my Jewish life.  As a club member, Men’s Club provided me with a network of Jewish fathers with whom I was able to share Jewish holidays and events with my young children.  Through my participation, I developed leadership skills working within my Men’s Club.  This led to my becoming active with the leadership of the Midwest Region of FJMC.  Eventually I was recruited to attend my first FJMC International Convention in the late 1980’s.  There I met several emerging leaders from all over North America with whom I remain friends to this day.  Working together, we helped build and strengthen several FJMC regions -- Midwest, Anshe Darom, K.I.O. and Northern New Jersey.  As I gradually became involved in FJMC governance and programming, I was now in a position to have an impact on the organization.  For example, I was able to play a central role in the development of the FJMC Keruv initiative, the annual Leadership Development Institute, and the Alterative Shabbat Minyan Community. 
 
Eventually I was given the honor and privilege of serving FJMC as its President and as President of the FJMC Foundation for Jewish Life (FJL). 
 
My experience with FJMC has been a central part of my life as a Jewish man, spouse, father, and now grandfather.  My joy has been to encourage other men to become involved and participate in FJMC programs, retreats and conventions.   No other organization of which I am aware gives Jewish men a comparable opportunity to share, learn, and experience Jewish life in such a friendly, warm and welcoming environment.  I am committed to continue my support of the FJMC community and the FJMC Foundation for Jewish Life so that future generations of Jewish men may benefit as have I.

Email Gary Smith, FJL Chairman, at foundationjl@gmail.com with your interest in becoming a Foundation Fellow to support FJMC.

What thoughts come to mind when you read or hear something on the news about a high profile breach like Equifax, Deloitte & Touche, SEC, JP Morgan Chase, Home depot or Target.  Well, yes they are all very large companies and yet if with all their vast financial and other resources, someone still found a way to target them (forgive the pun).
 
And yet, if you are like most, your reaction is “I am too small to target” or “I have no valuable information that someone would want, much less profit from. I don’t want to be the bearer of bad news, but if you think like that you open yourself and all you have worked for to extreme risk.
 
So, here are a few questions for you to think about in evaluating information you possess.

• Does your business accept credit cards.
• Do you maintain patient or client information such as account numbers, credit card numbers, tax returns, contracts, email addresses or other pertinent personal information. 

What do you think the consequences of ignoring a problem like this are (this is not Y2K 18 years later)?  Regulator fines, costs of remediation and notification to affected parties currently range from $408 per health record up from $380 last year and $233 for other records up from $225 last year.  Now the sobering news according to WebMD - You’re more likely to experience a data breach of at least 10,000 records (27.9%) than you are to catch the flu this winter (5–20 %).  Do the math to calculate just this part of the cost!  Then factor in the other hard costs above, add the softer but harder to calculate costs and remember insurance doesn’t cover this unless you have specific coverage with specific wording.
 
We haven’t even mentioned the costs of litigation especially if you lose personal information, the damage to your business reputation or worse yet, its’ continued existence.  For the average small business the likelihood of a breach contributing to closing your doors within 6 months is at 60%.
 
I want to highlight one of the breaches I referred to above because of not only the impact it had on so many but also some of what was spawned in its’ aftermath.  The security breach at credit reporting company Equifax has exposed sensitive information such as Social Security numbers and addresses of up to 143 million Americans or almost half our population.  
 
Equifax said the breach happened between mid-May and July 2017, discovered the breach on July 29 and took another 5 weeks to go public on September 7, although many Equifax insiders were already selling their holdings in the stock.
 
Unlike most if not all other high profile breaches few citizens even realized that Equifax, or for that matter the other large credit reporting agencies, had the extent of their information in its’ possession.
 
New York Attorney General Eric Schneiderman launched a formal investigation into the breach. Similarly the House Judiciary Committee had a hearing to investigate the data breach as did the House Financial Services Committee.  And even the Consumer Financial Protection Bureau is looking into the breach.

Several laws were passed by the states to hold more accountability and oversight for credit reporting agencies and the regulations have also extended into the insurance, financial and professional arena.
 
There are steps you can take to mitigate risk.  Ignoring them is not one of them!  One of those steps you can do is to go to this link https://www.equifaxsecurity2017.com where you will not only get a free credit report for Equifax but also Transunion and Experian.  Also, you can see if your credit was impacted with any of the breaches that have affected these American systems.

Richard Freiberg, is the Director of Business Development for SMLR Group, a cyber security firm providing products and services focusing on, promoting, and enforcing breach prevention, governance, and cyber assessment.

This issue is prepared by a bunch of guys who are continuing to GIVE BACK to FJMC.  We invite you to also give back to FJMC through your participation and most importantly through donations supporting FJMC as Friends of FJMC.  Participate by clicking on “Become a Friend of FJMC” on www.FJMC.org or contact Gary Smith at gsmith@fjmc.org.

Send your comments to Richard Gray at rgray@fjmc.org.  We want to hear from you. HWR is a publication of the FJMC.

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